Pregnancy Debate Revisited: To Induce Labor, Or Not?

Inducing labor at 39 weeks may involve IV medications and continuous fetal monitoring. But if the pregnancy is otherwise uncomplicated, mother and baby can do just fine, the latest evidence suggests.

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Originally published on August 9, 2018 11:14 pm

Healthy women with normal pregnancies can opt to have labor induced without worrying that the decision will make a cesarean section more likely, according to a major study published in this week's New England Journal of Medicine.

Obstetricians currently induce labor when a delivery has failed to progress, or if a woman is far overdue for giving birth. But when women who have no medical need for induced labor have talked to their doctors, "We've been saying, 'Well you know one thing you need to know is it does increase the C-section rate,' " says. Dr. Uma Reddy, an obstetrics researcher at the National Institute of Child Health and Human Development.

That advice was based on some older medical research. But researchers had doubts about that conclusion. So Reddy helped organize a study involving more than 6,000 first-time mothers with uncomplicated pregnancies, to put the idea to the test.

Half the pregnant women followed the normal course of labor; the other half had labor induced when the baby was full term, at 39 weeks. Overall, mothers and babies did fine when labor was induced with a drug.

"I think the most surprising finding was a decrease in the C-section rate," Reddy says.

That rate dropped from 22 percent among the women who weren't automatically induced to 19 percent for those whose labor was induced. Dr. William Grobman, the study's first author and a professor of obstetrics at Northwestern University, says it's an important goal to reduce the rate of cesarean sections in the U.S. So even a small percentage drop in the rate can have benefits overall.

But an individual woman might or might not consider that 3-percentage-point drop a big deal. "I think that's not really for me to decide," he says. "I think that's for patients to decide."

As expected, women who opted to have their labor induced spent more time in the labor and delivery suite.

Even so, Grobman says, "I also think it's important to recognize women who planned to be induced had fewer days in the hospital and their children had fewer days in the hospital after delivery."

The study found that women whose labor was induced were less likely to develop pre-eclampsia, an abrupt and life-threatening increase in blood pressure. Their babies were less likely to need help breathing. So all in all, it seemed medical intervention was a net plus.

That was certainly the story for 33-year-old Kelli Rojek, a Chicago woman who opted into the study and whose labor was induced. She thought about the risk of having a longer labor.

"The concern I was most aware of was that it can slow down labor and it can cause some headaches or nausea afterward," she told NPR.

But she also saw benefits.

"It was actually rather convenient for us," she says, "because we have a dog at home and we were able to call our families and say, 'Hey, we're going to go in at 11 p.m. on this day, and can you guys come up to take care of the dog and then come up to the hospital afterward?' "

Quick labor runs in her family, Rojek says. By 6:30 the next morning, her son, Harrison, came into the world.

"The doctor actually told me that I should never share my story with my friends," she says, "because they wouldn't want to hear how fast and easy things went!"

Lisa Kane Low, immediate past president of the American College of Nurse-Midwives, says the study was done well and provides useful information but that she is concerned that doctors and their patients will be nudged toward this more medical approach to childbirth.

"Some of the things that go along with an induction may not be part of what they had planned for their overall birth experience," Kane Low tells Shots. "It does require an IV, it does require that you have continuous electronic fetal monitoring to be safe, and it requires the use of different medications in order to start the labor process. And all those things need to be factored into what someone was hoping for their overall birth experience."

And the potential benefits can be hard to convey, Kane Low says.

"If you say to somebody, 'We could really reduce your risk of a cesarean by inducing your labor,' people who are very fearful of a cesarean may say, 'OK, I'm willing to [make that] trade-off and take the medical induction, even though that's not what I might want because it's going to reduce my risk.' But, yet, the absolute reduction is very small, overall."

Plus, this study was done under optimal conditions, she notes. The hospitals all followed the latest recommendations about when to do a C-section, and the women were 23 or 24 years old, on average — which is younger than the general age of women who give birth.

The March of Dimes, which has a campaign to encourage women to have full-term deliveries, issued a statement noting that because the study group was so selective, "[m]ore widespread implementation of induction at 39 weeks may yield much less favorable results, and thus should be considered with caution."

The study did not compare the overall costs of induced labor versus the traditional path — which can end in vaginal delivery, cesarean section or induced labor.

Reddy agrees that there are balancing pluses and minuses behind the decision to induce labor. "I think it's going to be up to the individual woman, because there are going to be strong opinions either way."

For years, obstetricians have cautioned women that if they chose to induce labor, they would increase the risk of needing a cesarean section. A large study out today in the New England Journal of Medicine upends that advice, as NPR's Richard Harris reports.

RICHARD HARRIS, BYLINE: Doctors induce labor when a delivery has failed to progress or if a woman is far overdue, but Dr. Uma Reddy says obstetricians have tended to steer women with uncomplicated pregnancies away from the procedure.

UMA REDDY: When they've asked about induction and they don't have a reason, we've been saying, well, you know, one thing you need to know is it does increase the c-section rate.

HARRIS: That advice was based on some older medical research, but Reddy, at the National Institutes of Health, had doubts about that conclusion. So she helped head up a study involving more than 6,000 first-time mothers with uncomplicated pregnancies to put the idea to the test. Half let nature take its course. The other half had labor induced when the baby was full-term at 39 weeks. And it turns out that, all in all, moms and babies did fine when labor was induced with a drug.

UMA: I think the most surprising finding was a decrease in the c-section rate.

HARRIS: Yes, it actually dropped from 22 percent, among the group who weren't automatically induced, to 19 percent for women whose labor was induced. Dr. William Grobman, the study's lead author and a professor of obstetrics at Northwestern University, says an individual woman might or might not consider that 3 percentage points drop a big deal.

WILLIAM GROBMAN: I think that's not really for me to decide (laughter). I think that's for patients to decide.

HARRIS: As expected, women who opted to have labor induced spent more time in the labor and delivery suite.

GROBMAN: That being said, I also think it's important to recognize women who planned to be induced had fewer days in the hospital and their children had fewer days in the hospital after delivery.

HARRIS: Women whose labor was induced were less likely to have high blood pressure - pre-eclampsia - and their babies were less likely to need help breathing. So, all in all, it seemed medical intervention was a net plus. That was certainly the story for 33-year-old Kelli Rojek, a Chicago woman who opted into the study and whose labor was induced. She thought about the risk of having a longer labor.

KELLI ROJEK: That was the concern that I was most aware of - was that it can slow down labor, and it can cause some headaches or nausea afterwards.

HARRIS: But she also saw benefits.

ROJEK: But it actually was rather convenient for us because we have a dog at home. And we were able to call our families and say, hey, we're going to go in at 11:00 p.m. on this day. And can you guys come up and take care of the dog and then, you know, come up to the hospital afterwards?

HARRIS: Quick labor runs in her family, she says. And by 6:30 the next morning, her son Harrison came into the world. Commenting on the study, Lisa Kane Low at the American College of Nurse Midwives says it was done well and provides useful information. But she's concerned that doctors and women will be nudged toward this more medical approach to childbirth.

LISA KANE LOW: How we message this can really confuse people. If you say to somebody, we could really reduce your risk of a cesarean by inducing your labor, people who are very fearful of a cesarean may say, OK, I'm willing to trade off and take the medical induction even though that's not what I might want because it's going to reduce my risk. But yet, the absolute reduction is very small overall.

HARRIS: This study was done under optimal conditions, she notes. And even there, it took 28 induced labors to prevent one cesarean section. Richard Harris, NPR News.